Weight Loss Surgery: Pre- and Post-Operative Care

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1 Weight Loss Surgery: Pre- and Post-Operative Care Dan Bessesen, MD Chief of Endocrinology; Denver Health Medical Center Professor of Medicine, University of Colorado School of Medicine

2 A Guide to Selecting Treatment Treatment BMI category Diet, physical activity, and behavior therapy With co-morbidity Pharmacotherapy With co-morbidity Surgery With co-morbidity + Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity Obes Res. 1998;6(suppl 2).

3 Lap Band Gastric Bypass Low Effectiveness Risk High

4 Comparison of Operations Lap band: 20% weight loss, very low mortality, 1% serious or 2.4% any complication Sleeve gastrectomy: 25% weight loss, 0.1% mortality, 2.4% serious or 6.3% any complication Gastric bypass: 30% weight loss, 0.2% mortality, 2.5% serious or 10% any complication Ann Surg 2013;257: ; Flum DR, N Engl J Med Jul 30;361(5):445-54

5 Benefits of Weight Loss Surgery the Swedish Obese Subjects Trial Bariatric Surgery vs. Usual Care Nonrandomized prospective controlled study 2010 pts. had surgery compared to 2037 contemporaneously matched controls Began 1987 Median follow up 14.7 years

6 Weight loss in the SOS JAMA. 2012;307(1):56-65

7 Bariatric Surgery is Associated with a Reduced Mortality: the SOS Study Adjusted Risk Patio=0.71 P=0.01 MI: 25 in control Group 13 in the Surgery group Cancer: 47 in The control group 29 in the surgery group Sjostrom L NEJM 2007:

8 Bariatric Surgery is Associated with a Reduced Mortality: VA Hospitals JAMA. 2015;313(1):62-70

9 Stampede Trial: Randomized Trial of Bariatric Surgery for T2DM N Engl J Med 2012;366: Previous studies suggested DM went into remission following bariatric surgery. 150 patients randomized to intensive medical therapy, gastric bypass or sleeve gastrectomy for management of type 2 diabetes Average baseline A1C was 9.2%

10 Stampede Trial: Benefits of Surgery for Type 2 Diabetes Parameter Medical Therapy (n=41) Bypass (n=50) Sleeve (n=49) P Value HbA1c<6 12% 42% 37% HbA1C<6 without DM med 0% 42% 27% % change in Tg -14% -44% -42% 0.08 % change in HDL 11% 28% 28% N Engl J Med 2012;366:

11 CV Medications Stampede Trial: N Engl J Med 2012;366:

12 Diabetes: Stampede Trial: 3 yr N Engl J Med 2014;370:

13 Benefits of Weight Loss Weight loss roughly Surgery 30% (50-60% of excess weight) with GBPS Maintained for >15 yrs Sleeve Gastrectomy: 25% less risk, less data Sleep apnea: Improved in 86% Hypertension: improved in half Gastroesophageal reflux: improved in most Urinary incontinence: improved in most Likely reduced mortality Annals of Surgery 237: ,2003 Sugarman

14 Risks of Bariatric Surgery: the LABS Study Flum DR, N Engl J Med Jul 30;361(5):

15 Who is a Good Candidate? BMI>35 kg/m 2 (30 with diabetes?) with comorbidities or >40 kg/m 2 without Age years Co-morbidities: Diabetes, sleep apnea, reflux > Hypertension, DJD Failed other forms of therapy No serious, active cardiac, pulmonary, or psychiatric disease

16 Managing Co-Morbidities Diabetes: immediately after surgery Stop sulfonylureas, cut insulin in half SMBG to adjust further, glucose declines rapidly Hypertension: immediately after surgery Stop diuretics, reduce other medications Arthritis Stop NSAIDS 10 days pre-op avoid for 6-12 months, maybe forever OSA: CPAP mask and pressure may need adjustment GERD, Urinary incontinence, hyperlipidemia: monitor

17 Medication Adjustments Essential medications should be administered in regular-release rather than sustained release formulations to offset the altered GI absorption after surgery. Tolerance can be improved by crushing the tablets or liquid formulations during the early postoperative days.

18 Peri-operative OCP Management OCP use is associated with a 3- to 4-fold increased risk of Venous Thromboembolism (VTE) HRT: increased risk of VTE for 90 days after inpatient surgery Stop 4-6 weeks pre-op Hold off on re-starting for at least 90 days postop Consider IUD for contraception 18

19 Pregnancy Fertility increases following weight loss. Avoid getting pregnant for the first year after surgery. BCP may not work because of poor absorption. Pregnancies need to be monitored, but outcomes appear good Lap band: May need adjustment if pregnant Vitamins, micronutrients critical

20 Micronutrient Deficiencies Primarily an issue with RYGB (Lap band can get thiamine deficiency) Predictable based on the bypassed segments Preventable with appropriate monitoring and supplementation Fe, Ca, B12, Vitamin D, Folate, Thiamine

21 Thiamine Without supplementation, can become acutely deficient in the immediate postoperative period especially if lots of vomiting. Sx: Double vision, ataxia, nystagmus, facial weakness, polyneuropathy, confusion, Wernicke s encephalopathy Beriberi Dry: symmetric peripheral polyneuropathy Wet: high output CHF Rx: 100 mg IV or IM daily x 7-14 days, the 10 mg/d orally till recovery

22 Iron Goal is to pick up early with monitoring. Most sensitive test is ferritin. To prevent all (female) pt should be on MVI. Prenatal MVI has increased Fe and Folate. If deficiency develops try oral replacement % may need parenteral replacement (Ferrlecit, INFed, Jenofer etc).

23 B12 Prevention: Recommended Daily Intake (RDI) about 1 mcg/d Oral crystaline B12: mcg/d Sublingual 500 mcg/d Nasal spray (Nascobal): 500 mcg/wk IM: 100 mcg/mo

24 Calcium/Vitamin D 25OH D deficiency is very common Obesity Dark skinned people Present pre-operatively in 30-40% Replace pre-operatively if deficient

25 Calcium/Vitamin D Post-operatively Ca citrate mg/d (has 400 u D) Prenatal MVI: u/d D Monitor 25OH D level every 3 months May reduce Ca supplement if person is tolerating and eating a lot of dairy. Consider DEXA at 1-2 years post-op and every 2 years after.

26 Mechanical Complications Anastamotic Leak First week after surgery Shoulder pain, tachycardia, abdominal pain Anastamotic ulcer Nausea, iron deficiency, abdominal pain Band erosion Abdominal pain, redness at port site Slipped band Nausea, abdominal pain

27 Summary Bariatric surgery has increasingly been shown to have dramatic health benefits and risk is declining due to improved surgery. There has been a shift from lap bands towards sleeve gastrectomies due to long term complicatoins. Nutritional deficiencies require ongoing supplementation following gastric bypass. Think about mechanical complications/ failures.

28 Bariatric Surgical Guidelines American Association of Clinical Endocrinologists/the Obesity Society/ American Society for Metabolic and Bariatric Surgery Evidence based A-D recommendations 164 recommendations 777 references 83 pages long

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